Objectives

1. Understand the problem of noncompliance with medication regimens for asthma.
2. Examine the literature pertaining to examination of factors underlying noncompliant behavior to medication regimens in asthmatic patients.
3. Review complementary and alternative medicine (CAM) use in general and potential use in asthma.
4. Explore the link between CAM use and noncompliance with prescribed medication regimens in asthma.
5. Summarize key implications of CAM use and medication noncompliance for physician consideration in patient treatment.

Abbreviations

CAM = complementary and alternative medicine

Compliance With Medication Regimens

The efficacy of any self-administered treatment is largely dependent upon the extent that patients comply with the treatment regimen. However, studies find that between one third and one half of patients who are prescribed medication do not take the medication, or do not take it as prescribed. Poor compliance with prescribed treatment regimens is a problem that spans across health conditions, methods of treatment, age, gender, and socioeconomic groups. Though patient noncompliance with prescribed medications is a serious obstacle for health-care providers, relatively little is known about the reasons for noncompliance.

Noncompliance has proven to be a particularly salient problem in the treatment of chronic conditions, such as asthma. In fact, noncompliance is considered the leading factor in poor asthma control.¹ Studies have shown that anti-asthmatic medications, such as inhaled corticosteroids, are highly effective in safely managing symptoms, making such medications the cornerstone of long-term asthma treatment. Despite the availability of these prophylactic medications, the rate of asthma-related morbidity and mortality and the rate of asthma-related hospitalization have increased substantially over the past² decades, and poor compliance with anti-asthmatic medications may be a reason. Estimates of compliance with asthma treatment range from 20 to 80% across various studies. Evidence suggests that patient outcomes from asthma treatment are negatively affected by poor compliance.² Thus, in order to reverse the trends in asthma morbidity and mortality, it is necessary to identify the factors affecting compliance and design interventions to change these factors.

A possible influence on patient compliance is the use of therapies that are not founded upon Western biomedical science, known as complementary and alternative medicine (CAM). Use of CAM has become increasingly popular in recent years for the treatment of many health problems, including asthma. A survey by the National Asthma Campaign found that 60% of people with moderate asthma and 70% of people with severe asthma use some type of CAM.³ The vast majority of people who use CAMs use them in conjunction with "conventional" treatments.⁴

While many researchers have considered the direct impact of complementary medicine on health status, such as beneficial pharmacologic mechanisms or adverse side effects, few have considered the indirect consequences of CAM use. The use of complementary medicine could also have less obvious effects, including an impact on the patient's compliance to conventional medications.⁵ If CAM users see alternative therapies as a viable substitute for conventional medicine for daily use, it could lead to decreased compliance. Because CAM use is prevalent among individuals with asthma and patients are supposed to use asthma medications even in the absence of symptoms, it is important to consider the indirect effects of CAM use on patient compliance with prescribed asthma medications.

Factors Affecting Asthma Medication Compliance

Noncompliance with prescribed medications has proven to be a very complicated behavior that results from a variety of factors. The factors affecting compliance can be patient-, physician-, or treatment-related. Despite the abundance of literature on the topic of compliance, there is no unifying model that explains compliance, and there is little consensus concerning the factors affecting compliance. In fact, in the numerous studies on compliance performed since 1975, more than 200 variables have been studied, but none has consistently predicted compliance.⁶ In reviewing the literature on patient compliance, it is important to note the inconsistency in methodology, as well as results. The definition of compliance is not always clearly stated in the literature, and, even when compliance is stated, it sometimes varies across studies. These variations make comparisons among studies difficult.

The best predictor of compliance that emerged from the literature was patients' attitude toward the treatment and medicine in general.⁶ Patients who have faith in the physician and the prescribed method of treatment are more likely to adhere to the treatment than patients who have a negative attitude toward treatment.⁷ The same is true of the parents of children with asthma. In a study by Riekert and colleagues,⁸ parents who had an unfavorable attitude toward the use of inhaled therapy were less likely to administer their child's treatment according to physician guidelines. Studies show that, to ensure better compliance, patients must believe that by following a prescribed regimen, the severity of their condition will be reduced.

Patients who have concerns regarding potential side effects of their medications are less likely to adhere to prescribed treatments. Concerns regarding side effects are more powerful predictors of compliance than sociodemographic factors, such as age, gender, and economic status.⁹ According to Chambers and colleagues,¹⁰ people who view asthma as a serious illness are more likely to adhere to asthma treatment than those who do not. The results of these studies indicate that many patients engage in an implicit cost-benefit analysis, weighing necessity against other concerns, such as inconvenience or side effects.⁹

Interventions aimed at improving compliance through education have been largely unsuccessful. A Cochrane review¹¹ of interventions to improve asthma compliance had very negative results, with less than half of the interventions having any effect. The poor results of asthma education interventions indicate that asthma knowledge may not be a strong predictor of compliance. The majority of the effective interventions were complicated and involved combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, and other forms of additional supervision or attention by a health-care provider.¹¹

The relationship between doctor and patient and its effect on patient compliance has been investigated, with results indicating that a strong relationship improves patient compliance.⁶ Effective communication between patients and providers and a patient-centered model of health-care delivery are positively correlated with patient compliance with treatment.¹² The study by Chambers and colleagues¹⁰ found that patients who see themselves as actively involved in the treatment process are more likely to follow prescribed treatments. The results of these studies indicate that a patient-centered approach to health care is effective in improving compliance.

CAM Use and Asthma

CAM use has become increasingly popular among patients from a variety of demographic and health backgrounds. In researching CAM use, it is important to consider the reasons some patients use CAM. According to a study by Vincent and Furnham,¹³ the most common reason patients use CAM is because they find the treatments to be effective. Another reason for CAM use, frequently cited in the study, is the ineffectiveness of traditional therapies.¹³ Use of CAM is more common among those with chronic illnesses than among other patients.¹⁴ Among individuals with chronic illness, such as asthma, seeking alternatives to conventional care may result from the belief that the medical establishment has not been able to "cure" the disease.

A notable result of the research is that negative attitudes toward conventional medicine actually may not be a strong predictor of alternative therapy use. There have been conflicting results across various studies concerning the correlation between negative attitudes toward, or experiences with, conventional medicine and alternative health-care use.

Another predictor of alternative therapy use is the desire to have control over therapy. Patients who want to be involved in their treatment are more likely to use alternative remedies.⁴ Patients also use alternative therapies because they believe that alternative therapies do not have side effects, while conventional medications are seen as potentially dangerous with long-term use.¹⁵

Although CAM users generally reported that they use unconventional treatments in addition to their conventional treatment, two studies found that patients may use alternative remedies in place of daily anti-asthmatic medication. The results of a study of CAM use among inner-city asthmatic children found that the children were likely to use prescribed medications only as a result of acute attacks and were unlikely to use preventive medication, instead using alternative therapies for day-to-day management.¹⁶ About 44% of these children's caregivers give alternative remedies as the first response to an asthma attack, and 59% of caregivers believe that alternative remedies are at least as effective as conventional therapies.¹⁶

The Link Between CAM Use and Medication Noncompliance

Although there have not been studies measuring the effect of alternative therapy use on compliance with asthma medication, much can be learned by examining the characteristics of patients who are noncompliant with asthma medication and who use alternative therapies, as well as the results of clinical studies on other disease groups. In a study of patients with cancer, alternative therapies did not affect compliance but provided patients with a means of coping and feeling in control.¹⁷

Insofar as patients see alternative medicine as useful for everyday treatment of asthma, it may impact compliance by reducing the use of conventional medicine for acute attacks. Thus, physicians should discuss with patients the preventive role of anti-asthmatic medications. Physicians should also discuss the potential side effects of alternative medicines, because many patients believe that alternative remedies are without side effects.

The most consistent, and perhaps most useful, piece of information to draw from these studies is that patients make decisions for themselves about treatment based upon their perception of what is effective. Assuming that patients will follow a treatment regimen prescribed by the doctor without any input or discussion from the doctor can lead to noncompliance, which can lead to poor treatment outcome and increased morbidity and mortality.

Instituting a patient-focused form of care, in which patients feel comfortable discussing their beliefs about prescribed medications and about the treatments they believe are effective, may lead to better outcomes for patients. Physicians should understand that patients' use of alternative therapies is not irrational, but rather is logically consistent with their own belief systems. Doctors must seek a more accurate understanding of everyday human behavior. Patients construct their own version of compliance. This leads to divergent views between physicians and patients that must be, at least, partially reconciled. Rather than rejecting alternative therapies offhand, physicians can negotiate with patients to find out how alternative therapies might be incorporated into conventional care.

Studies of CAM use indicate that CAM users want to be in control of their health care. Thus, if they can have more control of their health care within the context of conventional health care, they may be more likely to use conventional medicine alone. A study by Chambers and colleagues,¹⁰ showing that patients who feel like they are active in the health-care process are more compliant, further supports the concept of patient-centered medicine. An important study by Clark and colleagues¹⁸ found that pediatricians participating in educational sessions focused on maintaining interactive discussions with patients, identifying underlying worries or concerns, and reaching agreement on short-term treatment goals and acceptable treatment regimens had improved outcomes for their patients and greater parental satisfaction. This study provides further evidence that patient-centered medicine is effective.

Conclusions

Not all alternative therapies are discordant with conventional medicine. Often, alternative therapies are based upon similar principles, similar to those of conventional medicine. This is particularly true of asthma therapy, which is undeniably rooted in ancient herbal medicine. Studies of the pharmacologic mechanisms of some herbal treatments indicate that they may be effective in treating asthma.¹⁹

            One problem facing physicians concerning patients with asthma is that some patients only use prescribed medication for acute attacks. Many patients believe that if they are not experiencing severe symptoms they do not require prescription medication, and patients see prescribed medicine as the last resort. Patients who do not adhere to medications and some patients who use alternative medicine view conventional medicine as having dangerous side effects with long-term use. In order to allay fears concerning side effects, doctors must develop a strong relationship with patients and fully explain any possible side effects of the medication. Studies show that patients sometimes believe that when doctors do not tell them about side effects, it is to convince them to take a medication that is not really safe.¹⁶

References

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